Chapter 47: Skin Integrity and Wound Care Nursing School Test Banks

1. The nurse determines that the clients wound may be infected. To perform an aerobic wound culture, the nurse should:

a.

Collect the superficial drainage

b.

Collect the culture before cleansing the wound

c.

Obtain a culturette tube and use sterile technique

d.

Use the same technique as for collecting an anaerobic culture

ANS: c

c. To collect an aerobic wound culture, the nurse uses a sterile swab from a culturette tube and sterile technique.

a. The nurse never collects a wound-culture sample from old or superficial drainage. Resident colonies of bacteria from the skin grow in superficial drainage and may not be the true causative organisms of a wound infection.

b. The nurse should clean a wound first with normal saline to remove skin flora before obtaining the culture.

d. The nurse uses different methods of specimen collection for aerobic or anaerobic organisms.

a. Nitrogen build-up is not the primary cause of pressure ulcer formation.

b. Prolonged illness or disease may place a client at risk for pressure ulcer development, but it is not the primary cause of pressure ulcers.

d. Poor nutrition may place a client at risk for pressure ulcer development, but it is not the primary cause of pressure ulcers.

REF: Text Reference: p. 1484

3. The nurse notes that a clients skin is reddened, with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as:

a.

Stage 1

b.

Stage 2

c.

Stage 3

d.

Stage 4

ANS: b

b. This description is consistent with a stage II pressure ulcer. A stage II pressure ulcer is defined as partial-thickness skin loss involving the epidermis and/or dermis. The ulcer is superficial and appears as an abrasion, blister, or shallow crater.

a. A stage I pressure ulcer is an observable pressure-related alteration of intact skin whose indicators may include changes in one or more of the following: skin temperature, tissue consistency, and/or sensation. The description is not consistent with a stage I pressure ulcer.

c. A stage III pressure ulcer has full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The description is not consistent with a stage III pressure ulcer.

d. A stage IV pressure ulcer has full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. The description is not consistent with a stage IV pressure ulcer.

REF: Text Reference: p. 1487

4. The client has rheumatoid arthritis, is prone to skin breakdown, and is also somewhat immobile because of arthritic discomfort. Which of the following is the best intervention for the clients skin integrity?

a.

Having the client sit up in a chair for 4-hour intervals.

b.

Keeping the head of the bed in a high Fowlers position to increase circulation.

c.

Keeping a written schedule of turning and positioning.

d.

Encouraging the client to perform pelvic muscle training exercises several times a day.

ANS: c

c. The frequency of repositioning should be individualized for the client; however, clients should be repositioned at least every 2 hours. The AHCPR guidelines recommend that a written turning and positioning schedule be used.

a. Clients able to sit in a chair should be limited to sitting for 2 hours or less.

b. Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development from shearing forces.

d. Pelvic muscle training may help prevent incontinence, but is not the best intervention for maintaining the clients skin integrity.

REF: Text Reference: p. 1515

5. On changing the clients dressing, the nurse notes that the wound appears to be granulating. An appropriate noncytoxic cleansing agent selected by the nurse is:

a.

Sterile saline

b.

Hydrogen peroxide

c.

Povidone-iodine (Betadine)

d.

Sodium hypochlorite (Dakins solution)

ANS: a

a. Pressure ulcers should be cleansed only with wound cleansers that are not cytotoxic, such as normal saline. Normal saline will not damage or kill cells such as fibroblasts and healing tissue.

b. Hydrogen peroxide is cytotoxic, and therefore should not be used to clean a wound that is granulating.

c. Povidone-iodine (Betadine) is cytotoxic and therefore should not be used to clean a wound that is granulating.

d. Sodium hypochlorite (Dakins solution) is cytotoxic and therefore should not be used to clean a wound that is granulating.

REF: Text Reference: p. 1518

6. A client requires wound debridement. The nurse is aware that which one of the following statements is correct regarding this procedure?

a.

It allows the healthy tissue to regenerate.

b.

When it is performed by autolytic means, the wound is irrigated.

c.

Mechanical methods involve direct surgical removal of the eschar layer of the wound.

d.

Enzymatic debridement may be implemented independently by the nurse whenever it is required.

ANS: b

b. Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to allow visualization of the wound bed, and to provide a clean base necessary for healthy tissue to regenerate.

a. Autolytic debridement uses synthetic dressings over a wound to allow the eschar to be self-digested by the action of enzymes that are present in wound fluids. The wound is not irrigated.

7. The nurse prepares to irrigate the clients wound. The primary reason for this procedure is to:

a.

Decrease scar formation

b.

Remove debris from the wound

c.

Improve circulation from the wound

d.

Decrease irritation from wound drainage

ANS: b

b. The gentle washing action of the irrigation cleanses a wound of exudate and debris.

a. The primary purpose of wound irrigation is not to decrease scar formation.

c. The primary reason for irrigating a clients wound is not to improve circulation, but to remove debris from the wound.

d. The primary reason for irrigating a clients wound is not to decrease irritation from wound drainage, but to remove debris from the wound.

REF: Text Reference: p. 1543

8. When turning a client, the nurse notices a reddened area on the coccyx. What skin care interventions should the nurse use on this area?

a.

Clean the area with mild soap, dry, and add a protective moisturizer

b.

Apply a dilute hydrogen peroxide and water mixture, and use a heat lamp on the area

c.

Soak the area in normal saline solution

d.

Wash the area with an astringent and paint it with povidone-iodine (Betadine).

ANS: a

a. The skin should be cleansed and completely dried, and a protective moisturizer applied to keep the epidermis well lubricated.

b. Hydrogen peroxide is cytotoxic and should not be used. A heat lamp is not necessary and would increase the clients risk of an accidental burn.

c. The area should not be soaked, as this may lead to maceration of the skin.

d. The area should not be cleansed with an astringent and painted with povidone-iodine. An astringent may cause excessive drying of the tissue, and povidone-iodine is cytotoxic.

REF: Text Reference: p. 1514

9. A client with a large abdominal wound requires a dressing change every 4 hours. The client will be discharged to the home setting where the dressing care will be continued. Which of the following is true concerning this clients wound-healing process?

a.

An antiseptic agent is best followed with a rinse of sterile saline solution.

b.

A heat lamp should be used every 2 hours to rid the wound area of contaminants.

c.

Sterile technique should be emphasized to the client and family.

d.

A dressing covering will allow the wound area to remain moist.

ANS: d

d. A dressing should support a moist wound environment if the wound is healing by secondary intention, such as with a large abdominal wound. A moist wound base facilitates the movement of epithelialization, thus allowing the wound to resurface as quickly as possible.

a. Only mild soap or saline may be used or saline. Antiseptics may be damaging to granulation tissue.

b. A heat lamp should not be used, as it will dry the wound and impair the movement of epithelialization.

c. Clean dressings may be used in the home setting.

REF: Text Reference: p. 1528

10. On inspection of the clients wound, the nurse notes that it appears infected and has a large amount of exudate. An appropriate dressing for the nurse to select based on the wound assessment is:

a.

Foam

b.

Hydrogel

c.

Hydrocolloid

d.

Transparent film

ANS: a

a. Foam dressings absorb exudate and debris while maintaining a moist environment. Topical agents, such as antibiotic ointment, also may be used with foam dressings. This would be the most appropriate type of dressing for this wound.

b. A hydrogel dressing provides moisture to a clean granular wound. A hydrogel dressing would not be appropriate for a wound with a large amount of exudate.

c. A hydrocolloid dressing interacts with the wound fluid to provide a moist environment. Hydrocolloid dressings may stay in place until the seal is broken. It would not be appropriate for a wound with a large amount of exudate that appears infected.

d. Transparent film protects from friction injury and may be left in place up to 7 days. It would not be appropriate for a wound with a large amount of exudate that appears infected.

REF: Text Reference: p. 1533

11. A client has a healing abdominal wound. The wound has minimal exudate and collagen formation. The wound is identified by the nurse as being in which phase of healing?

a.

Primary intention

b.

Inflammatory phase

c.

Proliferative phase

d.

Secondary intention

ANS: c

c. During the proliferative phase, the wound fills with granulation tissue (including collagen formation), the wound contracts, and the wound is resurfaced by epithelialization.

a. Primary intention is not a phase of wound healing. Wounds that heal by primary intention have minimal tissue loss, such as a surgical wound. The edges are approximated, and the risk of infection is low.

b. During the inflammatory phase, platelets gather to stop bleeding, a fibrin matrix forms, and white blood cells reach the wound, clearing it of debris.

d. Secondary intention is not a phase of wound healing. Wounds that heal by secondary intention have loss of tissue, such as a pressure ulcer. The wound is left open until it becomes filled by scar tissue.

REF: Text Reference: p. 1493

12. A client comes to the emergi-center after an injury. The nurse implements appropriate first aid for the client when:

a.

Removing any penetrating objects

b.

Elevating an affected part that is bleeding

c.

Vigorously cleaning areas of abrasion or laceration

d.

Keeping any puncture wounds from bleeding

ANS: b

b. If a client is bleeding, the nurse applies direct pressure and elevates the affected part.

a. When a penetrating object is present, it is not removed. Removal could cause massive, uncontrolled bleeding.

c. Vigorous cleaning can cause bleeding or further injury. Abrasions and minor lacerations should be rinsed with normal saline and lightly covered with a dressing.

d. Puncture wounds are allowed to bleed to remove dirt and other contaminates.

REF: Text Reference: p. 1527

13. The nurse is concerned that the clients midsternal wound is at risk for dehiscence. Which of the following is the best intervention to prevent this complication?

Placing a pillow over the incision site when the client is deep breathing or coughing.

ANS: d

d. A strategy to prevent dehiscence is to use a folded thin blanket or pillow placed over an abdominal wound when the client is coughing. This provides a splint to the area, supporting the healing tissue when coughing increases the intra-abdominal pressure.

a. A client who has an infection is at risk for poor wound healing and dehiscence. However, prophylactic use of antibiotics is not the best intervention to prevent dehiscence.

b. Using appropriate sterile technique is always important to prevent the development of infection. It is not the best intervention to prevent dehiscence.

c. Keeping sterile towels and extra dressings at the clients bedside will not prevent wound dehiscence.

REF: Text Reference: p. 1494

14. After a head injury, the client has thin drainage coming from the left ear. The nurse describes this drainage as:

a.

Serous

b.

Purulent

c.

Cerebrospinal fluid

d.

Serosanguinous

ANS: a

a. Serous drainage is clear, watery plasma.

b. Purulent drainage is thick, yellow, green, tan, or brown.

c. The nurse does not know that this drainage is cerebrospinal fluid without further testing. The nurse should describe the drainage by its appearance (i.e., serous).

d. Serosanguineous drainage is pale, red, and watery: a mixture of clear and red fluid.

REF: Text Reference: p. 1494

15. Which nursing entry is most complete in describing a clients wound?

d. Serosanguineous drainage is not caustic to the skin and the risk of skin, breakdown from exposure to this fluid is low.

REF: Text Reference: p. 1503

17. The client is scheduled for a dressing change. When removing the adhesive tape used to secure the dressing, the nurse should lift the edge and hold the tape:

a.

At a 45-degree angle to the skin surface while pulling away from the wound

b.

At a right angle to the skin surface while pulling toward the wound

c.

At a right angle to the skin surface while pulling away from the wound

d.

Parallel to the skin surface while pulling toward the wound

ANS: d

d. To remove tape safely, the nurse loosens the tape ends and gently pulls the outer end parallel with the skin surface toward the wound.

a. Tape should not be pulled in a direction away from the wound, as this may cause the wound edges to separate.

b. Holding the tape at a right angle to the skin surface may pull on the wound bed, causing separation of wound layers, or may damage the underlying skin.

c. Holding the tape at a right angle to the skin surface may pull on the wound bed, causing separation of wound layers or may damage the underlying skin. Tape should not be pulled in a direction away from the wound as this may cause the wound, edges to separate.

REF: Text Reference: p. 1537

18. When cleaning a wound, the nurse should:

a.

Go over the wound twice and discard that swab

b.

Move from the outer region of the wound toward the center

c.

Start at the drainage site and move outward with circular motions

d.

Use an antiseptic solution followed by a normal saline rinse

ANS: c

c. To cleanse the area of an isolated drain site, the nurse cleans around the drain, moving in circular rotations outward from a point closest to the drain.

a. The nurse never uses the same piece of gauze or swab to cleanse across an incision or wound twice.

b. The wound should be cleansed in a direction from the least contaminated area, such as from the wound to the surrounding skin. The wound is cleaned from the center region to the outer region.

d. An antiseptic solution is not used to clean a wound, as it may be cytotoxic.

REF: Text Reference: p. 1543

19. The client has a large, deep wound on the sacral region. The nurse correctly packs the wound by:

a.

Filling two thirds of the wound cavity

b.

Leaving saline-soaked folded gauze squares in place

c.

Putting the dressing in very tightly

d.

Extending only to the upper edge of the wound

ANS: d

d. The wound should be packed only until the packing material reaches the surface of the wound. Wound packing that overlaps onto the wound edges can cause maceration of the tissue surrounding the wound. It also can impede the proper healing and closing of the wound.

a. The wound should be packed to the upper edge of the wound to prevent dead space and the formation of abscesses.

b. The gauze should be saturated with the prescribed solution, wrung out, unfolded, and lightly packed into the wound.

c. The wound should not be packed too tightly. Overpacking the wound may cause pressure on the tissue in the wound bed.

REF: Text Reference: p. 1536

20. The nurse is aware that application of cold is indicated for the client with:

a.

Menstrual cramping

b.

An infected wound

c.

A fractured ankle

d.

Degenerative joint disease

ANS: c

c. Direct trauma such as fractures or sprains may be treated with cold. The application of cold can initially diminish swelling and pain.

a. Application of heat to reduce muscle tension and pain would be more appropriate for the client with menstrual cramping.

b. The application of cold is not indicated for the client with an infected wound, as it reduces the blood flow to the area. This would limit the number of macrophages to clear the area of bacteria and would lessen the nutrient supply to the already impaired tissue.

d. The effects of heat application would be more beneficial to the client with degenerative joint disease.

REF: Text Reference: p. 1555

21. The client has a stage IV ulcer. In accordance with the Agency for Health Care Policy and Research (AHCPR), the nurse recommends that the client should have a:

a. A foam mattress is recommended for pressure reduction in clients at high risk for developing a pressure ulcer.

c. A rotokinetic bed is recommended for clients who are at risk for or have developed atelectasis and/or pneumonia.

d. A static support surface is not recommended for a client with a stage IV ulcer. It is used for clients at high risk for developing a pressure ulcer.

REF: Text Reference: p. 1516

22. The nurse uses the Norton Scale in the extended care facility to determine the clients risk for pressure ulcer development. Which one of the following scores, based on this scale, places the client at the highest level of risk?

a.

6

b.

8

c.

15

d.

19

ANS: a

a. According to the Norton Scale, a lower score indicates a higher risk for pressure ulcer development. The total score ranges from 5 to 20. The client at highest risk would be the client with a score of 6.

b. According to the Norton Scale and these scores, this would not be the client at highest risk for pressure ulcer development.

c. According to the Norton Scale and these scores, this would not be the client at highest risk for pressure ulcer development.

d. According to the Norton Scale and these scores, this would not be the client at highest risk for pressure ulcer development.

REF: Text Reference: p. 1495

23. The client requires support and an abdominal binder is ordered. The nurse correctly implements the use of a binder by:

a.

Using it as a replacement for underlying dressings

b.

Keeping it loose for client comfort

c.

Having the client sit or stand when it is applied

d.

Making sure the client has adequate ventilatory capacity

ANS: d

d. After applying the binder, the nurse should assess the clients ability to ventilate properly, including deep breathing and coughing.

a. Wounds should be entirely covered with dressings; the binder is applied over the dressing.

b. The binder should not be loose, or it will be ineffective in providing support.

c. The client should be lying supine with head slightly elevated and knees slightly flexed for application of the abdominal binder.

REF: Text Reference: p. 1551

24. The client is brought into the emergency department with a knife wound. The nurse correctly documents the clients wound as a(n):

a.

Contusion wound

b.

Clean wound

c.

Acute wound

d.

Intentional wound

ANS: c

c. A client with a knife wound is an example of an acute wound. An acute wound is caused by trauma from a sharp object.

a. A contusion is a closed wound caused by a blow to the body by a blunt object, resulting in a bruise.

b. A clean wound is a wound that contains no pathogenic organisms, such as a closed surgical wound that does not enter the GI, respiratory, or genitourinary (GU) system.

d. An intentional wound is a wound resulting from therapy, such as a surgical incision.

REF: Text Reference: p. 1489

25. The nurse is planning a program on wound healing and includes information that smoking influences healing by:

26. To reduce pressure points that may lead to pressure ulcers, the nurse should:

a.

Position the client directly on the trochanter when side-lying

b.

Use a donut device for the client when sitting up

c.

Elevate the head of the bed as little as possible

d.

Massage over the bony prominences

ANS: c

c. Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development from shearing forces.

a. The client should not be positioned directly on the trochanter, as this can create pressure over the bony prominence.

b. Donut-shaped cushions are contraindicated because they reduce blood supply to the area, resulting in wider areas of ischemia.

d. Bony prominences should not be massaged. Massaging reddened areas increases breaks in the capillaries in the underlying tissues and increases the risk of injury to underlying tissue and pressure ulcer formation.

REF: Text Reference: p. 1515

27. The client is experiencing low back pain and is to have an aquathermia pad applied. The nurse recognizes that safe application of heat to a clients injury includes:

a.

Providing a timer for the client

b.

Allowing the client to adjust the temperature for comfort

c.

Placing the pad directly onto the area requiring treatment

d.

Using the highest temperature that is tolerated by the client

ANS: a

a. An application should last only 20 to 30 minutes. Providing a timer for the client will help prevent injury to the tissue.

b. The temperature setting is fixed by inserting a plastic key into the temperature regulator. In many institutions, the central supply room sets the regulators to the recommended temperature.

c. The nurse does not place the pad directly on the clients skin. To prevent injury, it should be covered with a thin towel or pillowcase.

d. The recommended temperature is 105 F to 110 F. It should not be used at the highest temperature that is tolerated by the client.

REF: Text Reference: p. 1559

28. In reviewing the clients nutritional intake, the nurse wants to recommend intake of foods that will specifically promote collagen synthesis and capillary wall integrity. The nurse suggests to the client to eat: